Inspection Report
Complaint Investigation
Capacity: 103
Deficiencies: 36
Sep 17, 2025
Visit Reason
State-compiled facility profile showing 20 inspections from 2023-01 to 2025-08 with deficiency history and complaint investigations.
Findings
The facility underwent multiple complaint and other inspections between 2023 and 2025, with numerous deficiencies cited including issues related to abuse reporting, medication errors, care planning, emergency preparedness, life safety code compliance, and resident care. Several inspections found no deficiencies, but significant concerns remain regarding resident safety, medication management, and emergency preparedness.
Complaint Details
The page includes multiple complaint investigations from 2023 to 2025, with detailed findings on allegations of abuse, neglect, medication errors, and other resident care issues. Several complaints were investigated with no deficiencies cited, while others resulted in multiple deficiencies.
Deficiencies (36)
| Description |
|---|
| R9-10-425.A. An administrator shall ensure that: R9-10-425.A.1.b. Free from a condition or situation that may cause a resident or an individual to suffer physical injury; |
| Subdivision of Building Spaces - Smoke Barrier Construction: Facility failed to properly fill penetrations in multiple areas of smoke barriers allowing smoke and heat to penetrate other wings. |
| Gas Equipment - Cylinder and Container Storage: Failed to have light switches 5 ft above finished floor in oxygen storage rooms and protect wall outlet receptacles from physical damage. |
| R9-10-403.F.1. Failed to ensure all allegations of abuse were reported to state agency and mandated entities within required timeframe for two residents (#11 and #13). |
| R9-10-403.F.3.b. Failed to ensure thorough investigation of abuse allegations and protect residents from further abuse during investigation for two residents (#11 and #13). |
| R9-10-403.F.4. Failed to implement written policies and procedures to prohibit and prevent abuse for two residents (#11 and #13). |
| R9-10-410.B.3.k. Failed to ensure one resident (#420) was free from misappropriation of medications (narcotic diversion). |
| R9-10-412.B.7. Failed to ensure one resident (#24) was not administered an unnecessary drug (duplicate insulin orders). |
| R9-10-414.A.1.d.vii. Failed to provide timely shower and dressing for one resident (#12). |
| R9-10-421.A.1.b.i. Failed to prevent, respond to, and report medication errors; one resident (#43) had significant medication errors. |
| R9-10-421.B.1.c. Failed to ensure medication administered only as prescribed; resident (#29) physician not notified as ordered for high blood sugar. |
| R9-10-421.D.3.d. Failed to establish policies to protect residents for storing, inventorying, and dispensing controlled substances; expired medications found and administered. |
| R9-10-422.1.c. Failed to develop corrective measures to minimize or prevent spread of infections; improper hand hygiene during medication administration observed. |
| R9-10-423.B.1.a. Failed to ensure food was palatable and served at safe temperature; multiple resident complaints of cold and unappetizing food. |
| R9-10-403.C.2.b. Failed to establish and implement policies and procedures for physical health and behavioral health services to protect resident (#20). |
| §483.20(b)(2)(ii) Failed to complete significant change MDS assessment timely for resident (#4). |
| §483.21(b) Failed to develop and implement comprehensive care plan for resident (#77) including treatment for pressure ulcer. |
| §483.25(b) Failed to prevent pressure ulcer and provide necessary treatment for resident (#77). |
| §483.25(d) Failed to ensure safe environment free from accident hazards for resident (#238) and adequate supervision to prevent medication accidents for resident (#74). |
| R9-10-425.A.11. Failed to maintain poisonous or toxic materials in locked, labeled containers inaccessible to residents; medications left unsecured at bedside for resident (#74). |
| 42 CFR 482.41 Nursing Home: Failed to develop and implement emergency preparedness policies and procedures including subsistence needs, training, testing, and drills. |
| Failed to provide safe means of egress; emergency exit doors blocked or malfunctioning. |
| Failed to maintain one-hour fire rated doors; fire/smoke barriers failed to close and latch properly. |
| Failed to perform quarterly testing of sprinkler systems as required. |
| Failed to inspect and maintain fire/smoke dampers or fusible links; no documentation of maintenance/testing in past four years. |
| Failed to properly document weekly generator testing and continuity/conductivity tests of emergency generator. |
| Allowed use of power strips improperly instead of wall outlets, risking electrical overload or fire. |
| Failed to provide record of electrical equipment tests, repairs, and modifications; blood pressure monitors lacked preventive maintenance stickers. |
| Failed to discard expired medications and ensure expired medications were not available for administration; expired meds found and administered. |
| R9-10-403.C.2.b. Failed to ensure one resident (#20) received treatment and services in accordance with professional standards of practice. |
| §483.20(f)(5) Failed to maintain accurate, complete, and accessible medical records for resident (#4). |
| R9-10-412.B.3. Failed to ensure at least one nurse present and responsible for providing direct care to not more than 64 residents; RN coverage inadequate. |
| R9-10-414.A.1.c.ii. Failed to update comprehensive assessment when resident (#4) experienced significant change. |
| R9-10-414.B.1. Failed to develop, document, and implement care plan within seven days after comprehensive assessment for resident (#77). |
| R9-10-414.B.2. Failed to review and revise care plan based on changes to resident (#4) comprehensive assessment. |
| R9-10-414.B.3.b. Failed to assist resident (#4) in maintaining highest practicable well-being according to comprehensive assessment. |
Report Facts
Inspections on page: 20
Total deficiencies: 50
Complaint inspections: 18
Total capacity: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| STEVE HUNT | Administrator | Named as facility administrator in facility information |
| Director of Nursing (DON) Staff #618 | Director of Nursing | Named in multiple deficiency findings related to abuse investigations, medication errors, and care planning |
| Assistant Director of Nursing (ADON) Staff #640 | Assistant Director of Nursing | Named in abuse and medication error investigations |
| LPN Staff #220 | Licensed Practical Nurse | Named in narcotic diversion deficiency |
| LPN Staff #710 | Licensed Practical Nurse | Named in medication administration and expired medication deficiencies |
| RN Staff #700 | Registered Nurse | Named in medication administration deficiencies |
| Social Services Director Staff #672 | Social Services Director | Named in abuse investigation interview |
| Staff #45 | Licensed Practical Nurse | Named in expired medication deficiency |
| Staff #33 | Licensed Practical Nurse / Wound Nurse | Named in wound care and skin integrity deficiencies |
| Staff #8 | Director of Nursing | Named in multiple deficiencies related to care planning and resident assessments |
| Staff #16 | Staffing Coordinator | Named in RN coverage deficiency |
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